Oregon Licensed RN Appeals Nurse

Job Summary

A company is looking for a RN Appeals Nurse (Utilization Review).

Key Responsibilities

• Conduct comprehensive clinical reviews of member and provider appeals
• Apply nursing expertise to develop clear appeal determinations in line with regulatory standards
• Interpret medical records and collaborate with physician advisors for accurate decision-making

Required Qualifications

• Active, unrestricted Registered Nurse (RN) license in OR, WA, ID, or UT
• Bachelor's degree in Nursing (BSN) or higher
• Minimum of 2 years of experience in health insurance, utilization management, or clinical appeals review
• At least 3 years of direct clinical care experience or equivalent
• Strong knowledge of medical necessity criteria and healthcare regulations